The theoretical basis for thinking in this paper centres on a particular aspect of the development of the self, development that takes place through introjective identification. Healthy development depends greatly on the availability of appropriate models of individuals, relationships and situations for such identification. These models may be found in the adults who care for the children, their relationship with the children and with each other, and the setting for care. Healthy development may also require the management of the child’s identification with inappropriate models, for example with other children in institutions for delinquent or maladjusted children.
Institutionalized children are likely to find the most significant models for identification within the institution itself, both in the institution as a whole and its subsystems and in individual staff members and children. This leads to the concept of the institution as a therapeutic milieu whose primary task may be defined as providing conditions for healthy development and/or providing therapy for damaged children. Thus all the child’s experiences in the institution contribute positively or negatively to his development, not only those more narrowly defined as education, individual or group therapy or child care. Indeed, it has been the author’s experience that the benefits of such provision my well be counteracted by more general features of the institution.
This formulation would then lead one to take a very wide view of the institution in considering its effectiveness in carrying out its primary task. One would include its whole way of func-tioning; its management structure, including its division into subsystems and how those relate to each other; the nature of authority and bow that is operated; the social defence system built into the institution; its culture and traditions. In line with the theme of this paper, one would consider these in the context of how far they facilitate the provision of healthy models for identification, or alternatively inhibit the provision of such models.
Although one regards the whole institution as the model, in practice, of course, the impact of the institution on its child clients is mediated to a considerable extent through its staff members, who are the individual models for identification. While it is true that they will have their own individual personalities with strengths and weaknesses as models, it is also true that the way they deploy their personalities within the institution will depend on features inherent
in the institution, the opportunities it gives staff for mature functioning or the limits it puts on this. The author has discussed elsewhere the severe limits that a traditionally organized nursing service imposes on the mature functioning of both trained and student nurses (Menzies Lyth, 1970; pp. 43—85).
Thus, in considering the adults as models, one would give attention to maximizing the opportunity for them to deploy their capacities effectively and to be seen by the children to do so. Indeed, one may go further: experience has shown that in a well-managed institution for children, the adults as well as the children actually gain in ego-strength and mature in other ways. The adults thus provide better models.
The author’s interest in the importance of the whole institution as a therapeutic milieu has developed over many years of working in two institutions for disturbed children where her formal role was that of management consultant and her task was to work with staff in keeping under continuous review the way the institution as a whole was functioning in relation to the primary task. The role involved both a considerable understanding of the way institutions function and a psychoanalytically based understanding of child development. Similarly, in a collaborative study with the National Orthopaedic Hospital designed to improve the care of young children making long stays and to mitigate the long-term effects of hospitalization, it was found necessary to pay considerable attention to the way the Cot Unit for young children was managed and related itself to the management of the hospital as a factor affecting the quality of child care.
Against this background, it would appear possible that views about the development of children in institutions have been unduly pessimistic. So many of the early investigations were done in institutions whose whole organization was inappropriate for healthy child development. For example, the bad effects of hospitalization on young children were demonstrated first in hospitals with inadequate maternal visiting and multiple indiscriminate care-taking by a large number of nurses which effectively prevented attachment between a child and his care-takers. The same has been true, on the whole, for children in day and residential nurseries. In fact, these institutions deviated much more from a good model of care than is realistically necessary, as also from the kind of setting a good ordinary family provides for a child to grow up in. More recent work provides some grounds for a more optimistic view of the developmental potential of children’s institutions. They can be operated very differently from, for example, the old-fashioned hospital and can come much closer to the good ordinary family.
The section that follows discusses in some detail ways in which institutions can be organized or reorganized so as to provide improved models for the child’s identification and for his development, and gives examples of work in institutions. I will comment on various aspects of this: ego-development, superego-development, the development of a firm sense of identity and of authority and responsibility for the self, attachment possibilities, the growth of a capacity for insight and confrontation with problems.
The Potential of the Institution as a Model for Identification
Delegation and Its Relation to Staff’s Attitudes and Behaviour
It is in general good management practice to delegate tasks and responsibilities to the lowest level at which they can be competently carried and to the point at which decision-making is most effective. This is of particular importance in children’s institutions, since such delegation downwards increases the opportunity for staff to behave in an effective and authoritative way, to demonstrate capacity for carrying responsibility for themselves and their tasks and to make realistic decisions, all of which are aspects of a good model.
But this has not traditionally been the practice in many children’s institutions; the functions, responsibilities and decision-making are centralized at a high management level, with a consequent diminution of the responsibility, authority and effectiveness of the staff more directly in contact with the children. In my consultancy with an approved school (a residential school for delinquent boys) I became involved in working with staff to change the management structure and functioning in one such area. The setting was traditional, with a matron who dispensed food in kind to the house mothers who provided meals for the staff and boys in the houses where the boys lived. There were all sorts of deficiencies and inefficiencies in the system, both practically in its effects on food provision and psychosocially in its effect on the behaviour of staff providing food and the models they presented to boys. The food allowance was not very generous and there were constant complaints about its inadequacy; indeed, boys were not very well fed. But the effect of the reality of the food allowance was compounded by the fact that, since the responsibility for food provision and decision-making lay with the matron, there was a notable tendency for the house mothers to disclaim their responsibility and authority; for example, to blame the matron if things went wrong, rather than feel an obligation to cope with them themselves.
A small example illustrates this point. Two boys went for a walk one evening and came back hungry. The house mother gave them two of the eggs she had been given for the breakfast next morning, thus leaving herself two short. She was disconcerted and angry when the matron would not – could not – give her more. Matron was blamed instead of the house mother’s taking responsibility for her own actions. The model presented to the children was one of irresponsibility and of blaming the other.
The system gradually changed. Ultimately the house mothers were given the money to buy the food themselves. With it they were explicitly given the responsibility and authority for the efficient use of the money. The matron gave up her authority and responsibility for direct food provision and instead became an adviser and supporter of the house mothers if they wished to use her in that way. The former central foodstore became a shop where the house mothers could spend their money if they wished, but they had no obligations to do so if they preferred to shop elsewhere.
In time there were a number of very positive effects of this change. The house mothers visibly grew in authority and stature as they faced and accepted the new challenge and, for the most part, very effectively took over the task of food provision. The task itself was more realistically and effectively performed. One heard less and less about scarcity, and the boys were actually better fed. Most importantly, the confrontation with scarcity and complaints about ineffective provision now became a face-to-face matter between the house mother, her colleagues in the house and the boys. The boys were thus given an important learning experience for life in the world outside: in learning to deal with scarce resources themselves, not just to complain about them. Initiative and ingenuity were freed. The resources of the estate itself, such as fruit, were better used and gardening by staff and boys developed on a considerable scale to augment food supplies. The therapeutic effects of the change in the staff models presented and in the participation of the boys in the new system can hardly be exaggerated.
There was another important consequence in the matter of ego-development and defences. As the author has described elsewhere (Menzies Lyth, 1970; see above pp. 43-85), members of an institution must incorporate and operate to a considerable extent the defences developed in the institution’s social system. Here a thoroughly paranoid defence system had developed around the provision of food. The matron was regarded as a ‘mean bitch’; if only she were more generous, everything would be all right. Responsibility on the part of the house mothers was converted into blame against the matron and the boys were collusively drawn into the system. This defence was primitive and anti-maturational, but gradually disappeared as the new system developed to be replaced by a more adaptive system of acknowledged responsibility and confrontation with reality.
The implications for staff as superego models may also be evident in the carrying of more mature authority for oneself and one’s own behaviour and the replacement of blame of the other by more realistic assessment of oneself and one’s own performance.
This is but one example of a series of similar changes that gradually changed the provision by staff of ego, superego and defensive models, the importance of which can hardly be over-stressed for children whose personality development is immature or already damaged or both. The ego and superego strength of staff was both fostered by the changes and given more opportunity to be effectively demonstrated to the children. They in turn were also involved more effectively in control over their own circumstances and given less opportunity to regard themselves as helpless and nonresponsible victims of uncontrollable circumstances. It was seen as essential to carry out these other changes so as to achieve consistency and avoid presenting the children with conflicting and confusing models.
Effective delegation implies more than taking responsibility and authority for oneself, however; it implies also that the individual can accept and respect the authority of superiors and be effectively accountable to them, and that he can take authority effectively for his subordinates and hold them in turn accountable for their performance. This is again important in the provision of models for children whose relationship with authority is immature and possibly already disturbed. Thus authority channels must be clear; staff must know to whom they are responsible and for what, and for whom they are responsible and for what.
It seems a fault in many children’s institutions that they do not handle authority effectively. There may be too much permissiveness, people being allowed or encouraged to follow their own bent with insufficient accountability, guidance or discipline. If this does not work (and it frequently does not, leading to excessive acting out by both staff and children) it may be replaced in time by an excessively rigid and punitive regime. Both are detrimental to child development. The ‘superego’ of the institution needs to be authoritative and responsible, though not authoritarian; firm and kindly, but not sloppily permissive.
Institutional Boundaries and the Development of Identity
An aspect of healthy development in the individual is the establishment of a firm boundary for the self and others across which realistic and effective relationships and transactions can take place and within which a sense of one’s own identity can be established. Young children and the damaged children in many institutions have not developed effective boundary control or a firm identity within it, and need help from the institution in doing this. How then can the institution provide models of effective boundary control? The institution as a whole must control its external boundaries and regulate transactions across them so as to protect and facilitate the maintenance of the therapeutic milieu. This function will not be considered in detail, since it is less likely to impinge directly on the children than the management of boundaries within the institution. Any institution is divided into subsystems some of which perform different tasks, as with the education and living subsystems in a residential school. Some of them do the same tasks for differed clients, for example a number of houses in the living area. The way these subsystems control their boundaries and conduct transactions across them is of great importance for the development of the children’s personal boundaries.
A danger in children’s institutions seems to be that the boundaries are too laxly controlled and too permeable and that there is too much intrusion into the subsystem from outside and into the individuals within it. There seems to be something about living in an institution that predisposes people to feel that it is all right to have everything open and public and to claim right of entry to almost everywhere at almost any time. Nothing could be more different from the ordinary family home which tends jealously to guard its boundaries, regulating entry and exit and, particularly, protecting its children both from unwarranted intrusions and from excessive freedom to go out across the boundaries. And nothing could be less helpful to the development of children in institutions.
Problems appear particularly in the children’s living space, their homes effectively while they are in the institution. It seems important therefore that these present a model of effective boundary control, with realistically regulated entry and exit by permission of the people in the subsystem, notably the staff, not an open front door through which people wander in and out at will. To put it differently, the members of the subsystem need to take authority for movement in and out.
This was an important aspect of the work in the Cot Unit in the Royal National Orthopaedic Hospital where, at first, the boundaries were much too open. The Unit opened directly into the hospital grounds and people walking there seemed to feel free to drop in and visit children en passant, often with very kindly intentions of entertaining and encouraging them. Further, the Cot Unit provided the most convenient means of access to the unit for latency children and people en route for that often stopped to spend time with the young children. The physical boundary between the Cot Unit and that for latency children was open and there was a good deal of visiting by older children and their families. Altogether the situation seemed highly inappropriate for the healthy development of the children. Individual children were too often ‘intruded into’ by strange, even if kindly, adults. Relationships between children, mothers and Unit staff could be disrupted by the visitors, as could the ongoing work of the Unit. So the external door was closed to all except members of the Unit. Unit staff and visiting families had the authority and responsibility to control or prevent unauthorized entry. At first an invisible notice saying ‘No Admittance Except on Business’ was hung in the space between the two units, and again staff and visiting adults helped to control the boundary. Later, a partition was built that effectively separated the two units and made boundary control much easier. The benefits of this boundary control to the ongoing life of the Unit and to the child patients were inestimable.
But there remained the problem of the large number of people from outside the Unit who had legitimate business there: surgeons, the paediatrician, pathology staff, physiotherapists, and so on. Their crossing of the boundary also needed to be monitored to mitigate possible detrimental effects to the children’s boundaries. Small children have not developed effective control of such contacts with people who may be strangers and who may do unpleasant, frightening or painful things to them, such as taking blood samples or putting them on traction. The normal way that such contacts are mediated for the child is through a loving and familiar adult who can comfort the child and negotiate on his behalf. It became the rule that such visitors approach the child through his mother if present, or through his assigned nurse, or both. Sometimes the visitor would be asked not to approach the child for the moment if the intervention could be postponed and if the adult care-taker judged the moment inappropriate, for instance if a child was already upset or asleep. The adults both protected the child’s bound-aries and presented models of boundary control.
Similarly, the transactions across the boundaries outwards which involved children were carefully monitored. Work was done with other hospital wards and departments to ensure consistency in the principles of care between their work and that of the Cot Unit. There was explicit agreement about where mothers or other family adults could accompany children, and so on.
Effective control over boundaries can have another positive effect on the development of identity. It gives a stronger sense of belonging to what is inside, of there being something comprehensible to identify with, of there being ‘my place’, or ‘our place’, where ‘I’ belong and where ‘we’ belong together. Children cannot get identity from or identify with a whole large institution. They get their identity through secure containment in a small part of it first, and only through that with the whole.
This raises the related issue of the desirable size of what is contained within the boundary if it is to be comprehensible to the child. Too often, it seems, the basic unit is too big. For example, a hospital ward of, say, twenty beds is too big for the small child, both physically and psychosocially. He cannot ‘comprehend’ it and risks getting lost and confused. The physical space does not contain him securely within its boundaries and the number of staff is such as to risk multiple indiscriminate care-taking, a care system which is inimical to the establishment of a secure identity since it makes it difficult for the child to become familiar with the identity of the other and to have his own identity consistently reflected back to him by the other (Menzies Lyth, 1975). The Cot Unit was fortunate in being a twelve-bedded unit, usually less than full which could be staffed by a staff nurse, three nursery nurses and a nursery teacher during school hours. It was physically quite small and secluded once the partition was built.
An effectively bounded small unit is likely to facilitate the development of an easily identifiable and relatively integrated group within the unit, with the staff as its permanent core. This was important in providing support to children and families in the distressing circumstances of long stay in an orthopaedic hospital and in helping to keep anxiety at tolerable levels. This in turn helped prevent the development of inappropriate and anti-maturational defences. In institutions for disturbed children it may also be important in facilitating therapeutic work with the children within the unit through using the dynamics of the group. In a sense it makes escape from appropriate confrontation with realities inside the unit more difficult and facilitates the process of them.
There are boundaries of a more subtle kind that are also significant in providing models for children, notably the boundaries of authority and responsibility. For example, the authority for running the unit needs to be firmly located in its head and his authority should not be undermined by people from outside such as his superior, directly intervening inside it. The authority and responsibility for managing the Cot Unit was delegated firmly to the staff nurse, and the ward sister did not cross that boundary although she still held ultimate responsibility and kept in close touch with the work there. The ward sister sustained this, although she found it personally depriving and frustrating to be thus distanced from the young children. Similarly, when the head delegates some tasks to his staff the authority needs to be clear and he should not transgress the boundary by direct intervention.
Problems can arise in institutions if the same people work at different times in different subsystems when their authority and the authority under which they operate can become unclear. For example, teachers in an approved school sometimes work in the living area outside school hours. If they continue to think of themselves as ‘teachers’ under the authority of the headmaster they are confusing an authority boundary, as the headmaster has no management responsibility for the living system. The headmaster in an approved school much concerned for the welfare of his teachers had to learn – painfully – not to think and talk of ‘my staff’ when they were working in the living area: similarly the heads of the houses had to learn to think of the ‘teachers’ as ‘their staff’ and take authority over them effectively. These may again seem strange preoccupations for people concerned with the care of children in institutions, but they do seem appropriate since confusion or inadequate definition of authority boundaries can confuse staff about who or what they are and threaten their own sense of identity and what they identify with. This confusion will subtly convey itself through their attitudes and behaviour to the children, with detrimental effects on their sense of identity and their development. The final point on this topic concerns the protection of the boundaries of the self and the management of transactions across them, with particular reference to the processes of projection and introjection and their effort on the sense of self. Excessive projection can and does change in a major way the apparent identities of both the projector and the recipient if he cannot control what he takes in. Both can feel unreal and strange to themselves and both can act strangely and inappropriately. Similarly, inappropriate introjections can create a false identity and an unstable sense of self. It seems to be a crucial responsibility of the staff in children’s institutions to control their own boundaries so as to manage the effects of both projection and introjection and hold them within realistic and therapeutic limits. In so doing they will help the children to control their projections and introjections and strengthen the development of a true and stable identity. Young children and disturbed children are likely to project massively into care-takers. Indeed, it is to some extent a normal method of communication, telling the other what the child is feeling or what for the moment he cannot tolerate in himself. For example, the apparent ‘consciencelessness’ of a delinquent child can result from the splitting off and projection of a harsh and primitive superego which is unbearable to the child. The deprived, inadequately mothered child may violently project into the care-takers an idealized mother figure with the demand that the care-taker be that mother and compensate for all his deprivations. The danger for the care-taker, and so for the child, is that the projections may be so compelling that the care-taker acts on them instead of taking them as communications. His personal boundaries are breached, his identity temporarily changed and the transaction ineffectively controlled.
The staff of approved schools, for example, may act on the projected primitive superego and treat the children in a rigid and punitive way which is anti-therapeutic. This represents an acting out by staff with children instead of a therapeutic confrontation with the problem. Or staff can respond to the demands for compensation for early deprivation by an over-gratifying regime which is equally anti-therapeutic, since it evades confrontation and real work with the problem.
Similarly staff must be alert to the introjections and false identifications which children use in their desperate search for a self and sense of identity. These may lead, for example, to false career ambitions in pseudo-identification with idols, identification with delinquent gangs, or apparent and sudden but false improvement based on pseudo-identification with the staff or the principles of the institution.
Inappropriate projections and introjections between children and staff are by no means the only problems. One must also take note of projections and introjections between staff and staff, between children and children and between subsystems. For example, it is fairly common to find in institutions a situation where all subsystems but one are said to be in a good state, but one is in a mess. Frequently this is less a reality than the results of intergroup projections, subsystems projecting their ‘bad’ into the one and encapsulating the ‘good’ in themselves. All such phenomena are, of course, anti-developmental and anti-therapeutic and real progress can be made only in so far as people and subsystems can take back what belongs to them, discard what does not and work with the external and internal reality of their situations.
This has always seemed to me one of the most difficult tasks confronting the staff of children’s institutions and one for which they need much help and support. This emphasizes the need for the staff to be a close and supportive group able to confront together the projection and introjection systems and to help rescue each other when one or more of them are caught. It requires a culture of honesty and mutual confrontation which is by no means easy to achieve. It requires also a certain permanency and long-standing relationship between the staff which is notoriously difficult to sustain in children’s institutions, which tend to have a high labour turnover.
A consultant from outside the group who can view the situation with a ‘semi-detached’ eye may be a great help here in understanding with staff the nature of the projections and introjections and helping to re-establish the basic identity of both the staff group and the individuals with it.
Institutional Provision for the Development of the Capacity for Relationships
The theoretical basis for the discussion here lies in the work of John Bowlby (1969) and many co-workers. Briefly, the capacity to develop lasting and meaningful relationships develops in accordance with the opportunity the child, especially the very young child, has to form secure attachments. The good ordinary family gives an excellent opportunity where the young child is likely to form a focal intense attachment, usually (though not always) with his mother. He forms other important although less intense attachments with others including his father, siblings, other relatives and friends, his attachment circle extending as he grows older. Moreover, the people in his circle of attachment also have attachments to each other which are important to him for identification. He not only loves his mother as he experiences her but identifies with his father loving his mother and extends his ‘concept’ of the male loving the female. For the most part, although not always, institutions have dismally failed to replicate that pattern. The multiple indiscriminate care-taking system in which all staff indiscriminately care for all children effectively prevents child-adult attachment. This has been traditional in hospitals and can also be seen in day and residential institutions for physically healthy children. The Robertsons’ film John (Robertson, James, 1969a,b) shows how multiple indiscriminate care-taking effectively defeats John’s efforts to attach himself to one nurse. Further, it has been my experience that multiple indiscriminate care-taking also tends to inhibit attachments between staff so that there is a dearth of attachment models for the children. The situation is of course often compounded by staff turnover, hospital wards being staffed largely by transitory student nurses and day and residential nurseries tending to have high labour turnover.
I am indebted to my colleague Alastair Bain (Bain and Barnett, 1980) for a dramatic observation of the child’s identification with an inadequate model of relationships in a day nursery and its perpetuation in his later relationships. The observation concerns what he calls ‘the discontinuity of care provided even by a single care-taker which occurs when a nursery has to care for a number of children’. He writes:
“Their (the children’s) intense needs for individual attention tend to mean that they do not allow the nurse to pay attention to any one child for any length of time; other children will pull at her skirt, want to sit up on her lap, push the child who is receiving attention away.”
One can see this very clearly in John. Bain goes on:
“…during the periods between moments of attention, the young child experiences his fellows as also receiving moments of attention… He will also experience as the predominant pattern of relationships between adult and child, a series of discontinuities of attention, a nurse momentarily directing her attention from one child to another… He and his moment are just part of a series of disconnected episodes.”
The follow-up of these children showed them to have identified with and to be operating on that model, the model of episodic and discontinuous attention, forming in turn a series of episodic and discontinuous relationships with their world shown through fleeting superficial attachments and also in episodic discontinuous play activities and later in difficulty in sustaining continuous attention at school. I have come to call this the ‘butterfly phenomenon’: the child flitting rather aimlessly from person to person or activity to activity.
Fortunately, institutions do not have to be like that. It is possible to eliminate multiple indiscriminate care-taking and get closer to the family model. Dividing the institution into small units with firm boundaries as described above provides something more like a family setting, even if it is still somewhat larger. Within that setting attachments between staff and children form more easily. Even further, with an institutional setting it is possible to provide something nearer to a focal care-taker by assigning children to a single staff member for special care and attention. What this would include varies according to circumstances and needs. In the hospital the assigned nurse took special care of the child and his family, helping the mother care for the child when she was present, doing most of the general care herself if the mother was absent. She escorted him to theatre or to post-operative care if the mother was not allowed to be present. She comforted him in distress, talking to him if he was verbal and especially talking through problems. For example, a child was overheard having an imaginary conversation with his absent mother on a toy telephone and saying: ‘Mummy, I know I’ve been a naughty boy and that’s why you don’t come to see me.’ The nurse picked that up and worked with the child about it. In residential settings there may be the importance of bedtime for deprived children, of outings like dental or medical visits, playing together, working with distress and problems, having a special relationship with the child and his family together if he is still in contact with his family.
Workers can never equal the mother’s almost total availability to the young child since staff have limited working hours, but experience has shown that deep and meaningful attachments can be formed between the child and the assigned care-taker. For example, in the Royal National Orthopaedic Hospital, a small boy came from overseas: his pregnant mother, with a large family of other children, could not accompany him and his father could rarely visit. The assigned nurse developed a closely attached relationship with him (her other assigned children having mothers present). She not only did general care but talked to him about his family, of which the boy had photographs, thus establishing some continuity. She also helped prepare him for going home to find a new baby by talking, by doll play and by relating to babies, of whom there were always some in the Unit. It was very moving to watch them together. Parting when it came was very painful for both, but for both the rewards were enormous. In particular, the child’s capacity for attachment was sustained.
The gaps in the availability of the focal care-taker are difficult for the child, but not impossible to handle. In small, firmly bounded units children do form subsidiary attachments to other adults, and indeed to each other, and the care-taking need not become indiscriminate. The Cot Unit had explicit reassignment plans when the assigned nurse was off-duty. Further, with older children in residential settings, adults can and indeed must also relate in an attached way to groups of children engaging in enjoyable activities with the group or handling the group in a state of distress or crisis.
In addition, the small bounded group gives a good setting for the adults to form meaningful relationships with each other. This not only again provides good models of attachment behav-iour but also facilitates reassignment when necessary. The child tends to accept the second adult more easily and to use him better if he has seen him in a good relationship with the first. In the hospital, for instance, when a child was admitted and accompanied by his mother, the nurse would frequently have relatively little to do with the child at first, but concentrated on building her relationships with the mother. The good relationship they established undoubtedly helped the child accept the nurse if and when the mother had to leave, and begin to form an attachment to her.
My references to transitory staff and high labour turnover may seem to suggest that attachments are always under threat from adults leaving. But in fact we found that in units operated as described there would be a dramatic fall in staff turnover. The Royal National Orthopaedic Hospital was fortunate that the Cot Unit was staffed by nursery nurses who were permanent staff and not by transitory student nurses. But in a profession, nursery nursing, that notoriously has an enormously high labour turnover, there was almost no labour turnover during the study and as the care method developed all three nursery nurses stayed over three years, an inestimable benefit for long-stay and repeat-stay children. The work had in fact become more challenging and rewarding and the attachment to the children increased the nurses’ wish and sense of responsibility to stay with the children.
The work is not only more rewarding, however, it is also more stressful. Multiple indiscriminate care-taking can in fact be seen as defence for staff against making meaningful and deep contact with any one child and his family, a contact which frees the child’s expressiveness and makes the care-taker more fully in touch with his distress and problems as well as his joys. It can be quite shattering temporarily for staff to move from multiple indiscriminate care-taking to case-assignment, a move which may include the disruption of concepts about what a child is like. One staff nurse said: ‘I have had to unlearn everything I thought I knew about children since you [the author] have been here.’ Too often staff think of the healthy normal child as one who is ‘settled’, calm, accepting of everyone who approaches him, relatively unprotesting about what is done to him. They need to learn that in the abnormal circumstances of the hospital, the ‘normal’ child is likely to be frightened or miserable quite a lot of the time, to protest at interventions, to object to the presence of strangers and to be apparently more difficult – certainly a more distressing child for adults to work with.
Again the staff may need help with this – help that can come from a strong attached staff group who support and care for each other, from senior staff, or from an outside consultant. In a sense one may say that the staff need to experience the same concern and support for their stresses as they are expected to provide for children and families, a consistency in the method of care.
I will conclude this section by trying to draw together some of the points I have made within a rather different theoretical framework. Bion (1967) has described the importance for the infant’s development of his mother’s capacity for reverie – that is, how she takes in his communications, contains and ponders over them intuitively but not necessarily consciously, and responds to them in a meaningful way. It is particularly important, in relation to fear and distress, that the mother can take in his projections and return them to the infant in a more realistic and tolerable version. The function of reverie is important also for staff in children’s institutions. It can be reverie in the individual staff member or it can be something analogous to reverie in group situations, staff talking things through in an intuitive way together. The communications on which staff must work are often massive and very disturbing and staff in turn need support of the kind I have mentioned.
Like the ordinary devoted mother (Winnicott, 1958) they need themselves to be contained in a system of meaningful attachments if they are to contain the children effectively. They need firmly bounded situations in which to work and they need the support of being able to talk things through in quieter circumstances away from the core of the children’s distress and problems.
The Developmental Effect of the Institution’s Social Defence System
The author has described elsewhere the development and operation of the social defence system in institutions (Menzies Lyth, 1970; see above, pp. 43-85). The institution develops, by collusive interaction among its members, a system of defences which appear in the structure, the mode of functioning and the culture of the institution. Continued membership tends to involve acceptance and operation of the accepted social defence system, at least while present in the institution. However, the social defence system is sustained and operated by individuals, notably staff members, and this plays a part in their effectiveness as models for identification. There appears to be a need for constant vigilance if the defence system operated in the insti-tution is to be sustained at a mature level and indeed to be adaptive rather than defensive, for it will be under constant threat. It will be under threat because the stress and disturbance present in the children will predispose staff to use massive defences against confronting the disturbance in a painful although potentially therapeutic way. I have referred to multiple indiscriminate care-taking as one such defence. It can be associated with massive denial of the meaning of the children s communications, with a manic defence that denies its seriousness with rigid punitive regimes which try to control disturbance rate than working it though. I also described above a paranoid defence system connected with the evasion of a difficult responsibility.
The children may be a threat in another way in that they in turn tend to operate massive and primitive defences against their distress which are in turn not only individual but also tend to become socialized as they relate to each other in various group situations. This may have a powerful effect on staff, who are usually outnumbered by children as the children try to force staff to enter into collusion with their social defence system. Hard work, courage and suffering are often needed if staff are to resist these pressures and sustain more mature defences as a model and as a facilitation of confronting and working through problems.
In the world of approved schools and institutions for delinquents such phenomena are known as subcultures in which problems such as homosexuality or violence are acted out away from staff or, sadly, sometimes with them, and are recognized to be inimical to the therapeutic culture of the institution.
Work done on a consultancy visit to an approved school may illustrate this. I was told first by professional staff that there was great discontent among the domestic staff in the living units. They felt they could not achieve a high enough standard of work and were not getting job satisfaction. I was at first unclear what I was supposed to do about this, but gradually I felt I was beginning to understand. I heard a lot about violence among boys, of which there had recently been more than usual – some of it very destructive. More than usually violent boys were said to have been admitted recently or were about to be admitted to the school. The professional staff were not only afraid of the boys’ violence, but were anxious also about the impulses to counterviolence they felt in themselves. Up to that point, they had not felt able to confront the violence adequately as a problem to be worked at. Instead they had developed an anti-therapeutic and subcultural method of trying to prevent it, by gratification and appeasement. They hoped, not necessarily consciously, that if they provided a very high standard of care in living units, they could in effect keep the boys quiet. Professional staff then put subtle pressures on domestic workers to provide a quite unrealistic living standard, a pressure which the domestic workers in turn accepted and tried to put into operation. In reality they could not and consequently suffered painful feelings of inadequacy and failure. We disentangled this in the course of a long day’s discussion during which professional staff faced their fears of violence more openly, realized that developing a subculture of dependency to counter a subculture of violence was not likely in fact to deal with the violence or to be therapeutic, and so became more able to work with the violence directly. The domestic workers were relieved of the projections into and pressures on them and could once again apply themselves to a realistically defined task from which they got satisfaction.1
Such subcultures are perhaps less likely to appear in institutions which have the features I have suggested as more appropriate for the development of the healthy self in the children – for example authoritative, responsible staff, well-defined delegation, small, fairly bounded units, effective opportunities for reverie. But no institution is likely to avoid them fully; hence my comment about the need for constant vigilance, possibly again with the help of a consultant.
I hope I have succeeded in justifying my optimistic view that institutions for children can be developed in such a way as to provide more effectively for the development of a healthy self than has too often been the case in the past and, unfortunately, is still too often the case in the present. Changes in the desired direction can and have been achieved in institutions, although often at the cost of considerable turmoil, doubt and uncertainty among staff while they are being made.
The effect of such developments on children has been encouraging. At the Royal National Orthopaedic Hospital, no children who had been hospitalized under the new care system showed the typical signs of institutionalization or of any serious damage to their development. There were problems but none serious, nor of a kind that could not be contained in the families and worked with there. Some of the children, indeed, seemed to have gained rather than lost ground. We acknowledge with respect and gratitude the major contribution many mothers made to this result, but it was also evident in unmothered children. I have already mentioned one small boy from overseas who actually developed well, but perhaps the most dramatic example was another small boy with foreign parents who were in this country but who very rarely visited. When the mother did come, she could not really make a relationship with him but only carried out a few simple tasks usually designed to make him look more like a boy from his own country. This was almost meaningless. On admission at nearly four years old he had no language, neither his own nor English, and had most violent temper tantrums so that, for example, due notice had to be given of interventions, so that he could be given tranquillizers in advance. Everyone except the author diagnosed him as mentally defective. The author diagnosed him as psychotic, not only on the direct evidence he presented but also from his history.
He had been driven from pillar to post, from foster home to residential nursery, day nursery and round and round again. He had passed much time in inadequate children’s institutions with no attachment, no containment, no good models. During his thirteen months in hospital (the longest continuous stay of any child) he was devotedly cared for by his assigned nurse and the nursery teacher especially, but also by other staff in the small, close attachment circle of the Unit. When he left he had an age-appropriate English vocabulary, had completely lost his temper tantrums, and had begun to use toys and other methods to work over in a constructive way his hospital experience. A fortunate coincidence for him was that the staff nurse had to resign her post for family reasons and decided to foster children as a means of working at home. She took the boy home with her, thus sustaining an important attachment. He then continued to develop well and settled well into a normal school.
The results in the desperately damaged boys in the approved school do not usually match up to that level, but it is notable that there is in general much less acting out in the school, fewer abscondings, less violence and much more constructive activity than one usually finds in such institutions. The results are also above average in terms of life performance in general and, in particular, in fewer of the repeated delinquencies that take so many such boys later into other institutions like Borstals, prisons or mental hospitals.
Much remains to be done, however, to convert other children’s institutions into places more suitable for children to grow up in a healthy way. Since powerful pressures are now evident in our society to put children into institutions, there appears to be an urgent and serious need to improve these institutions if children are to be given the best opportunities for development and the ‘vicious circle’ effect of early institutionalization prevented, such as delinquency, mental illness, or repeated institutionalization.
1. What I have described as subcultures of violence and dependency are closely linked with Bion’s formulation of basic assumptions of fight/flight and dependency as observed in small groups (Bion, 1961). The point Bion makes about the basic assumptions is that they are characterized by psychotic phenomena, are evasive of reality instead of confronting it, and do not evidence a belief in work as a means of carrying out tasks or in the time and suffering needed to do so. So they are anti-therapeutic.